Centre 38106 Range Road 275 Red Deer County, AB T4S 2L9 P: 403. 754.6371; F: 403.346.9840 Website: www.rdcounty.ca Email: [email protected] PLUMBING PERMIT APPLICATION FORM Permit Applicant: Owner Contractor Application Date: Other Permits Required (under separate application): Building Electrical Gas PSDS Estimated Completion Date:

Development Permit No.: New Home Warranty No.(if applicable):

Owner Name: Mailing Address: City: Province: Postal Code: Phone: Cell: Email: Fax:

Plumbing Contractor Name: Mailing Address: City: Province: Postal Code: Phone: Cell: Email: Fax:

Hamlet/Subdivision Name: Tax Roll No.: Street/Rural Address: Unit: Lot: Block: Plan: Legal Subdivision: Part of: ¼ Section: Township: Range: West of: M Directions: Description of Work: Plumbing installation has not started Plumbing installation in progress Plumbing installation complete TYPE OF PROJECT TYPE OF WORK NUMBER OF NEW FIXTURES Residential New Kitchen Sinks: Washing Machines: Multi-family Addition Basins: Laundry Tubs: Commercial Renovation Showers: Floor Drains: Industrial Accessory Building Bathtubs: Grease Traps: Institutional Secondary Suite Toilets: Bidets/Water Fountains: Other: Basement Development Urinals: Other Fixtures: Manufactured/Mobile Home Total Fixtures: RTM Other: Total Footprint: sq ft sq. m. BACKFLOW DEVICE INFORMATION [multi-residential (1.5” meter or larger), commercial, industrial] Sprinkler System Irrigation System Domestic Water Line Boiler Feed Line

Permit Applicant Declaration: The permit applicant certifies that this installation will be completed in accordance with the Safety Codes Act and Regulations and work will commence within 90 days. The permit applicant/owner acknowledges that as per Section 12(2) of the Alberta Safety Codes Act, Red Deer County is not liable for any decision related to the system of inspections, examinations, evaluations and investigations including but not limited to a decision relating to their frequency and the manner in which they are carried out. F.O.I.P. Notification: Personal information is collected under the authority of Section 33(c) of the Alberta Freedom of Information and Protection of Privacy Act and will be protected under Part 2 of that Act and section 63 of the Safety Codes Act. It will be used for processing permit applications, issuing permits, safety codes compliance monitoring and verification. Questions regarding the collection of personal information can be directed to the FOIP Coordinator 403.350.2150.

Journeyman’s Name (print) Journeyman’s Signature Homeowner ‘s Signature (homeowner permit only) Homeowner Declaration: By signing this I hereby certify that I own/will own and occupy this dwelling. Journeyman’s Certification No.:

Permit Fee: $ Building Permit No.: File No.: Receipt No.: Region: Division: *SCC Levy: $ Cash Debit Credit Card Cheque No.: Total Fee: $ Credit Card No.: Exp. Date: *SCC levy 4% of the permit fee with minimum of $4.50 and a maximum of $560.00 Name on Credit Card: Signature on Card: OFFICE USE ONLY Permit Validation Section to be completed by the Permit Issuer: Special Conditions: Site inspection(s) are required to ensure compliance with the Safety Codes Act of Alberta.

Permit Issuer’s Name: Permit Issuer’s Signature: Designation No.: Permit Issue Date: For inspections, please contact IJD Inspections Ltd. 403-346-6533 or http://www.ijd.ca/request-an-inspection. 2021.01.18